This post is part of the Basic Guide to Suturing series. It provides an overview of the steps you need to take when assessing and then preparing for closure of a wound. 

As a general guide you would normally;

1.   1.  Assess
2.   2.  Gather required equipment
3.   3.  Prep & Drape
4.   4.  Anaesthetise
5.   5.  Clean/Irrigate
6.   6.  Suture (see Overview of Suturing Techniques for more details)
7.   7.  Bandaging/Dressing and ongoing wound-care

Steps 3, 4 and 5 can be rearranged, depending on your operating environment, equipment, wound and personnel. In the Emergency Department in particular, the order is flexible, and steps may have to be repeated. For example, you might clean the wound first to remove of the majority of the debris so that you can use your local anaesthesia in a semi-sterile environment. Once the local is working, you could give the wound a more thorough clean again.   

Assessment of Wound

Your assessment of the wound is ultimately going to determine how choose to manage it. Some important characteristics to discuss and examine are;

◘  Mechanism of injury?

◘  How old is the injury?

◘  Where is the injury, how big and how deep?
◘  Examine for foreign bodies and/or contamination
◘  Assess neurovascular status and any search for any deep tissue issue injuries (e.g. tendons)
◘  Need for tetanus prophylaxis
◘  Identify risk factors that may affect wound healing

Based off history and examination consider requirement for any imaging. 

Tip: Achieving some degree of haemostasis is an important step in adequately assessing the wound. In emergency departments this can often be achieved by; applying direct pressure with a gauze pad for 10-15 minutes, or 1% lignocaine with adrenaline (other methods exist).

Indications (for suturing)

In general sutures can be used for wounds that have occurred within 18hrs of the initial injury. This in order to achieve;

◘  Haemostasis

◘  Bring tissues edges together, close defects

◘  Prevent further infection
◘  Securing drains or lines

Contraindications (for suturing)

Concern about wound infection is the primary reason not to close a wound primarily. Several relative contraindications exist for suturing and other methods of wound closure should be considered.

◘  Animal bites

◘  Foreign bodies/debris in wound

◘  Requires excessive tension
◘  Current infection
◘  Patients presenting with wounds >24hrs after initial injury

Equipment

Once you have decided to close the wound you need to get the appropriate equipment.

1.   1.    Sterile gloves
2.   2.    Sterile Syringe 5-10ml
3.   3.    Suture pack
4.   4.    Sutures
5.   5.    21-30G Needles (25G is commonly used.)
6.   6.    Local Anaesthetic (e.g. Lignocaine)
7.   7.    Antiseptic solution
8.   8.    Sharps bin
9.   9.    Formal Drapes (as required)
10. 10.    Dressings
11. 11.    Consider other Personal Protective Equipment

Preparation

If you have not done so already inform the patient about what you are about to do, and make sure they are happy to proceed. Written consent is often not required when repairing simple lacerations and verbal consent will often suffice. If unsure, talk to your senior clinician.

1.   1.   Get all your equipment (as listed above) and a trolley (where able)
2.   2.   Open your equipment using sterile technique and create a sterile field.
3.   3.   Ensure that both you and the patient are positioned in a comfortable manner.
4.   4.   Good lighting.
5.   5.   Wash your hands
6.   6.   Place on a pair of a sterile gloves (regular gloves may also be appropriate).
7.   7.   Clean the wound/s.
8.   8.   If painful consider anaesthetising at this point before any further cleaning.
9.   9.   Irrigate with chosen solution
10. 10.   Normal Saline, Dilute Iodine or even tap water (see below)
11. 11.   Use your drapes (creating a hole if necessary) to cover the wound 
12. 12.   If you have not done so already, Get ready to anaesthetise!

Tip: It is may seem obvious, but it is less painful to anaesthetise through the wound, rather than break through fresh skin with a needle to achieve numbness.

References

Stitch Up by Martin Clifton

Suturing, one of the fundamental skills of a medical practitioner has been around since the time of the Ancient Egyptians. Originally used by the Egyptians for burial preparations, the art of suturing has gone through several renditions throughout the course of history. Yet it still remains one of the chief ways of allowing us to manipulate the body to help others and achieve wound closure.

This series of posts aim to provide a simple guide to the art of suturing. Covering common suture techniques, knot tying, surgical instrumentation, suture material and suture selection. Importantly, it will also cover some other aspects of medicine which are vital to understand to achieve optimal suture results:

◘ Anatomy

◘ Principles of wound care

◘ Anaesthesia

I’ve provided a collection of resources so that people can select those items which are most beneficial to their learning style. Look out for resources as they are added under the sections below.

The presentation below is an overview of the material covered throughout this series.

Suturing 101 - Basic Surgical Skills for Medical Students and Junior Doctor

Wound Assessment

History  and examination are the building blocks of wound assessment, and ultimate influence what you end up doing. Some important steps are highlighted below.

◘ Mechanism of injury

◘ How old is the injury

◘ Where is the injury, how big and how deep

◘ Examine for foreign bodies and/or contamination

◘ Assess neurovascular status and any search for any deep tissue issue injuries (e.g. tendons)

◘ Need for tetanus prophylaxis

◘ Identify risk factors that may effect wound healing

This is by no means a complete list of questions you should ask when a patient presents with an injury. The normal components of a standard medical history (e.g. allergies) are also an important component of your treatment strategy. 

Anaesthesia & Preparation

◘ Before you close the wound

◘ Anaesthetics for Wound Management

◘ Optimising Local Anaesthetic Administration
◘ Digital Ring Block
◘ Biers Block

Suture Techniques

◘ An overview of Suturing Techniques

◘ Simple interrupted suturing

◘ Vertical Mattress
◘ Continuous Subcuticular
◘ Horizontal Mattress

Knot Tying

◘ Grog's Surgical Knots

◘ Basic Square Knot (Boston University)

◘ Two Hand Tie (Boston University)
◘ One Hand Tie (Boston University)
◘ Instrument Tie (Boston University)

Other Management Options

◘ Staples

◘ Glue

◘ Steristrips

Take your Basic Surgical Skills a step further

There are lots of different resources out there to help further refine your skills.
Closing the Gap
Different DIY suture models

References & Resources

1. 1. Basic Laceration Repair, NEJM (2006)
2. 2. Stitch Up by Martin Clifton

Chest X-Ray by Tor Ercleve

A systematic approach to Chest X-Ray (CXR) interpretation is essential to avoid missing significant pathological changes. With time and practice, interpreting CXRs will become easier, but first you have to find an approach that works for you.

The Basics

Before we begin with our approach to CXR interpretation, there are some principles we need to understand. A chest radiograph uses ionising radiation (usually 0.06 mSv) to paint a picture of your internal chest anatomy. The dose of radiation from an individual X-Ray is typically of little concern. However if you're worried check out XKCD's Guide to Radiation.

It is important to note that not all chest structures will be seen on CXR, and some will only show up if an abnormality is present (e.g. pleura).

Adapted from Wikipedia

4 Main Radio-densities

When looking at a CXR it's important to get a grasp on anatomical & foreign structures will be presented. There are 4 main Radio-densities to be aware of;

◘  Gas = Black

◘  Fat = Dark grey

◘  Water = Light grey

◘  Bone/metal = White

Rule 1: The denser the tissue, the whiter it will appear on x-ray.

Views

The next thing to consider is what angle are you viewing the chest from. The most common view is the Posterior-Anterior, otherwise known as a PA film. Other views are;

◘  Anterior-posterior (AP)

- Exaggerates heart size. 

- For less mobile or emergency patients.

◘  Lateral CXR

◘  Decubitus

◘  Oblique

◘  Supine or standing?

 

Interpreting for Beginners

We will start with the most simple of interpretation methods that apply nearly to all radiological images.

Rule 2: Always check Patient Details & Film Type.

◘  Who: correct patient

◘  When: correct day

◘  Why: what is the indication for the test / what are we looking for?

◘  What: what is the image of?

These basic questions will set you in good stead before commencing on the intricacies of interpreting. Next consider, what systems are present in the image, and then identify and examine them.

Mnemonics can be a good way of making sure that you don't miss anything when your first starting out. I've included a number of examples below. At the end of the day, your approach to CXRs is basically what works for you.

Simple Interpretation
1. Check patient details & technical adequacy.    

2. ABC Method – Airways, breathing, circulation.

ABC Method

Airways

◘  Trachea

◘  Hilar

Breathing & Bones

◘  Lung fields, pleura. Costophrenic Angles.

◘  Bones – destruction, #s

Circulation & Soft tissues.

◘  Mediastinum – width.

Another option is the;

DCBAA Method
D ocuments
C hest

◘  Compare lungs

◘  Airway (right place, deviation)

◘  Mediastinum

◘  Diaphragm

◘  Pleura

B ones

◘  Look at all the bones.

◘  Pattern recognition.

A bdomen

◘  Frees gas - erect Chest X-Ray under diaphragm. 

A nd Areas

◘  Additional areas that you wouldn't normally look at.

Common Mistakes
This list of common mistakes comes courtesy of Duncan;

◘  Did I stop looking after I found one abnormal finding? Do I need to complete my system?

◘  What are the commonly missed things in this situation/imaging modality?

◘  Am I tired / bored / distracted?

◘  How do the clinical findings and the radiographic findings correlate?

◘  Have I examined the patient properly (ED juniors, a shoulder x-ray is not a substitute for an examination)

Beyond the Basics - ABCDEFGHI Method

A  Airway (midline, patent)

B  Bones (eg, fractures, lytic lesions)

C  Cardiac silhouette size

D  Diaphragm (eg, flat or elevated hemidiaphragm)

E  Edges (borders) of the heart (to rule out lingular and left middle lobe pneumonia or infiltrates)

F  Fields (lung fields well inflated; no effusions, infiltrates, or nodules noted)

G  Gastric bubble (present, obscured, absent)

H  Hilum (nodes, masses)

I   Instrumentation (eg, lines, tubes)

The DRSABCDE Method

Developed by Matthew Lumchee, the DRSABCDE method brings back the familiarity of the Basic Life Support algorithm whilst throwing in some additional features to CXR Interpretation. For more details on this method checkout Lifeinthefastlane.com.

Got any more tips for approaching Radiology?

Then Share Them Here.

Further Resources

1. 1. Chest X-Ray Atlas - http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/cxr/atlas/cxratlas_f.htm
2. 2. Medline: Chest X-Ray (info for patients) - http://www.nlm.nih.gov/medlineplus/ency/article/003804.htm
3. 3. Radiology Masterclass - http://radiologymasterclass.co.uk/index.html
4. 4. Radiopedia.org (an atlas)
5. 5. The Radiology Assistant

Not quite sure how to interpret an ECG? 

Then have a look at A Quick Guide to ECG.

References

Crausman RS. The ABCs of chest X-ray film interpretation. Chest. 1998 Jan;113(1):256–7.

'Big Muscles' via Zecode.info

Musculoskeletal Clinical Exams are used in conjunction with the appropriate history taking to ascertain the likelihood of a disorder within the bone or muscles structures. The two main categories into which these disorders can be split into are Disease and Trauma, as summarised below.

Disorders of the Musculoskeletal System by Aaron Sparshott (CC 3.0 license)

This will be a brief overview of the principles of a Musculoskeletal Exam, with a closer look later at the assessment of the;

• Spine
• Upper Limb
• Lower Limb

Each segment will take a look at the anatomy associated with the area, methods to assess function and clinical signs.

In cases particularly involving trauma, it is important to try and determine the mechanism of action. For example the circumstances that led up to and after the patient breaking their arm.

Symptoms
Symptoms to look for when diagnosing a musculoskeletal disorder;

• Pain
• Joint Instability
• Stiffness
• Skin Changes
• Tenderness
• Swelling and,
• probably the most important from the patient's perspective is a loss of function

If pain is present it's is important to investigate further. A helpful mnemonic for exploring aspects of pain is NILDOCAAFIAT. Shown below is what each letter stands for;

Nature

Intensity

Location

Duration

Onset

Contributing

Aggravating

Alleviating

Frequency

Impact

Attribute

Treatment

The nature of the Musculoskeletal exam can probably be best summed up by this quote from Kenneth E. Sack, MD.

A comprehensive assessment of the musculoskeletal system includes inspection and palpation of joints and soft tissues as well as evaluation of joint range of motion and neuromuscular function. CURRENT Rheumatology Diagnosis & Treatment.

Below is a diagram outlining the general process of a musculoskeletal clinical exam.

General Steps in a Musculoskeletal exam by Aaron Sparshott (CC 3.0 license)

The most common further investigation to perform is some form of diagnostic imaging. Such as;

• Xray
• Ultrasound
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)

Resources

An overview of the Musculoskeletal Exam by Colon H. Wilson is freely available from the NCBI.

Clinical Assessment of the Musculoskeletal System provided by Arthritis Research UK.
Download Here

Other Clinical Exams
Cardiovascular | Respiratory | Gastrointestinal | Neurological | Musculoskeletal

 

Examination of the eye in a clinical environment can involve a number of separate tests, but is usually guided by the patient’s presenting complaint or requirements (e.g. vision needs to be assessed for ability to drive).

It is important to note that examination of the eye can also provide clues to diseases and disorders well beyond the eye itself. Ophthalmoscopic examination is a useful skill that is not just limited to neurological and eye examinations. Changes on fundoscopy can also be seen in systemic diseases such as hypertension and diabetes.

Taking a History
When approaching an eye examination, there are three basic things that should be investigated when taking a history. That is, does the eye,

See right (e.g. Diplopia, Transient Loss of Vision (Amaurosis Fugax), Flashing Lights, Photophobia)

Look right (e.g. yellow sclera: jaundice, red eye: conjunctivitis)

Feel right (e.g. pain, dry eyes, etc)

It is also important to specifically consider ocular history (e.g. contact lens or glasses/visual aids, lazy eye’ as a child, etc). These aspects form the foundations of any history taking concerning the eye, and you would proceed with the history (PMHx, FHx, etc) as per any other medical condition.

Common presenting complaints associated with the eye can be remembered as DAMPCHNFFS.

Diplopia

Amaurosis

Mists

Pain

Colour vision disturbance

Haloes

Night Blindness

Flashes

Floaters

Scotomata

Basic Eye Anatomy & Physiology
Anatomy of the Eye (Chabacano on Wikipedia)

Internal Eye (Normal Fundus. From the University of Michigan)

Ocular Muscles
Extrinsic Muscles that move the eye are; Lateral Rectus (innervated by CN6), Superior oblique (innervated by CN4), Superior rectus (innervated by CN3), Medial rectus (innervated by CN3), Inferior rectus (innervated by CN3) and Inferior oblique (innervated by CN3). The diagram below highlights the bony orbit and the location of some these muscles. Nerves are also identifiable.

Adapted from Patrick J. Lynch on Wikipedia

Intrinisic eye muscles: Ciliary (innervated by CN3), Sphincter pupillae (innervated by CN3) and Dilator pupillae (innervated by Superior cervical ganglion - T1)

Visual Pathway

Reflexes
Light Reflex: Shining light into one eye causes constriction of iris muscles on both sides

 

Accommodation Reflex: Directing eyes from a distant object to a near object causes constriction of iris muscles on both sides.

Vestibulo-Ocular Reflex: Moving the head causes movement of the eyes to maintain a stable image during rapid head movement.

The Basic Performa
Ideally, the eye examination consists of a number of elements shown in the diagram below.

Elements of the Eye Exam
External Examination of the Eye
External examination of eyes consists of inspection of the eyelids, surrounding tissues and palpebral fissure.

Remember the four L’s: lymph nodes, lacrimal apparatus, lids and lashes

Visual Acuity
Assessing the subject’s visual acuity is important as it provides a context for other elements of the exam. Visual acuity is typically assessed by a Snellen chart (which can be hand held or mounted) in the clinical environment, but other charts types (e.g. Allen figures, illiterate E charts, Landolt C, etc) are also used. A pinhole test will improve vision with most refractive errors.

Other charts are usually used to accommodate the patient’s unique knowledge (e.g. English maybe a second language) and mental capacity, so as to provide an indication of visual acuity without a requirement to read or verbalise.

Visual acuity is measured by comparing the person’s ability to see objects at standardised distances. The standard definition of normal visual acuity is 20/20 (US) or 6/6 vision (typically used in Europe & Australia as it refers to metres). Often Snellen Charts will have these values (e.g. 6/5, 6/6, 6/12) along the side.

Example
Australian Law requires that drivers have a corrected visual acuity of 6/12 or better in both eyes. This means that they must be able to at least see an object or person at 6 metres, that a normal person could see at 12 metres.

Each eye should be tested separately with a chart while the other is covered.

It is essential to always get the patient’s best corrected visual acuity. That is, allow them to wear their contacts or glasses.

Heirarchy for low vision
Snellen acuity –> count fingers –> hand motion –> light perception –> no light perception

Pupillary Function
Assessment of pupillary function includes examining the pupils for equal size, regular shape, reactivity to light (direct & consensual) and accommodation. It is important to test for relative afferent pupillary defect (RAPD) by swinging your pen torch from pupil to pupil. The video below demonstrates a patient with this defect.

These steps can be easily remembered with the mnemonic PERRLA: Pupils Equal and Round; Reactive to Light & Accommodation.

Ocular motility
The effective movement of the eyes should be tested to ascertain whether a problem exists either within the ocular muscles, or the nerves that supply them. Knowing these muscles and their innervations is obviously crucial to understanding any abnormalities that arise during testing. A useful mnemonic for remembering the muscles and their innervations is LR6SO4R3. Where the numbers refer to the cranial nerves; LR equals Lateral Rectus; SO equals Superior Oblique; and R equals all other ocular muscles.

Slow tracking or "pursuits" are assessed by the 'follow my finger' test, in which the examiner's finger traces an imaginary "double-H", which touches upon the eight fields of gaze.

Visual fields
Testing the visual fields consists of confrontation field testing, in which each eye is tested separately to assess the extent of the peripheral field.

Intraocular Pressure
Glaucoma, characterized by elevated intraocular pressure, optic disk cupping and atrophy, and loss of vision, is one of the three leading causes of acquired blindness in the Western world. Tonometry is the fundamental screening test for detecting elevated intraocular pressure.

Ophthalmoscopy
Ophthalmoscopic examination may include visually magnified inspection of the internal eye structures and also assessment of the quality of the eye's red reflex.

 

Other Tests
Common tests include the HRR pseudoisochromatic plates or the Ishihara plates. The City University Color Vision Test is nearly able to adequately provide an indication of the severity of all colour deficiencies.

Further Resources

• Eye Stimulator Tutorial -  http://cim.ucdavis.edu/EyeRelease/Interface/TopFrame.htm
• The Eyes Have It - http://www.kellogg.umich.edu/theeyeshaveit/screening/index.html
• Ophthalmology Simplified - http://www.ophthalclass.blogspot.com/
• Root Atlas - http://www.rootatlas.com/ 
• The physical examination of the eye by Robinett DA, Kahn JH. Emerg Med Clin North Am. 2008 Feb;26(1):1-16, v.
  http://www.ncbi.nlm.nih.gov/pubmed/18249254 

Also checkout the 35 Golden Rules of EyeCare.

Other Clinical Exams
Cardiovascular | Respiratory | Gastrointestinal | Neurological | Musculoskeletal

Obstetrics is the field of medicine which encompasses the care of a woman during pregnancy and childbirth. In that way it is very unique, as when assessing these patients, your actually also assessing another the child. Consequently, the approach to history taking in Obstetrics whilst similar to other fields of medicine, includes a number of additional components.

The following is a guide to taking an Obstetric History, that will ensure you miss none of the key components.

Presenting Complaint
What is the problem that brought you to the hospital/clinic?

Some common presenting complaints include;

1. ◘   Bleeding
2. ◘   Abdominal Pain
3. ◘   Hypertension
4. ◘   Physiological complaints due to pregnancy

The patient may also be presenting as part of standard antenatal care (as per your local guidelines).

History of Presenting Complaint
Often there will be overlap between the history of the presenting complaint and the history of the current pregnancy.

History of Current Pregnancy
The history of current pregnancy should ideally be considered by the different trimesters to date. This will be useful for understanding common issues that arise at each stage, and also determining appropriate antenatal care and management.

General Questions

1. ◘   Last menstrual Period (LMP)
2. ◘   Estimated delivery date and approximate Gestational Age.
3. ◘   Any concerns about your pregnancy
4. ◘   What are your expectations regarding your pregnancy

First Trimester

1. ◘   Further details regarding menstrual history (as below)
2. ◘   Was the Pregnancy planned?
3. ◘   How was the pregnancy confirmed?
4. ◘   Signs and symptoms of pregnancy.
5. ◘   How/has the pregnancy been dated (e.g. dating Ultrasound Scan)?
6. ◘   What tests and scans have you had to date?
7. ◘   Current medical illnesses and medications.

Second Trimester

1. ◘   Any problems during second 3 months?
1. o  Bleeding, vaginal discharge, urinary problems and so on.
2. ◘   Last visit to the doctor?
1. o  Has an Ultrasound scan (e.g. morphology scan) been done?
2. o  Blood tests to date?
3. o  Blood pressure?
4. o  Growth of foetus, placenta location.

Third Trimester

1. ◘   Any issues after the first 6 months of your pregnancy?
1. o  Bleeding, vaginal discharge, urinary problems, labour pain.
2. o  Blood pressure
3. o  Glucose
4. o  Test results
2. ◘   Any plans or ideas about method of delivery.

Past Obstetric History
Gravidity: the number of times a woman has been pregnant, regardless of the outcome.
Parity: the number of times a female has given birth to a baby.

There are many different methods and protocols by which Gravidity and Parity are denoted, please be aware of your local policy and documentation guidelines.

A simple system commonly used in the UK is;

GPx+y

where

G= Gravidity, P = Parity: X = (any live or still birth after 24 weeks);

Y = (number lost before 24 weeks)

A woman who has never given birth is a nullipara, a nullip, or para 0.
A woman who has given birth two or more times is multiparous and is called a multip.
A woman in her first pregnancy and who has therefore not yet given birth is a nullipara or nullip. After she gives birth she becomes a primip.

A woman who has given birth once before is primiparous, and would be referred to as a primipara or primip.

Details of each pregnancy

1. ◘   Dates of deliveries
2. ◘   Length of pregnancies
3. ◘   Singleton/twin and so on
4. ◘   Induction of labour/Spontaneous
5. ◘   Mode of Delivery
6. ◘   Weight of babies
7. ◘   Gender of babies
8. ◘   Complications before, during and after delivery

Number of miscarriages, terminations and/or ectopics – with appropriate details.

1. ◘   This question should be asked as some patients will not consider the above situations as pregnancy.

Any difficulties conceiving and any treatment/management to date for sub-fertility.

Past Gynaecological History
If it hasn’t been so already, you should first gain a Menstrual History as appropriate.

1. ◘   1st day of last menstrual period
2. ◘   Duration and regularity of normal cycle
3. ◘   Flow: heavy/light, clots, number of tampons/pads used
4. ◘   Pain

Last Cervical Smear (Pap Smear): when and results.

Any Gynaecology Surgery?

1. ◘   D&C
2. ◘   Loop excision of transitional zone (LETZ)
3. ◘   Previous C-Sections

Treatment or investigations for; ectopic pregnancy, pelvic inflammatory disease, infertility
This may be an appropriate place to take a Sexual History (see sexual history for further details).

Past Medical & Surgical History
Current or past illnesses

1. ◘   Hypertension
2. ◘   Diabetes
3. ◘   Epilepsy
4. ◘   Thyroid (hypo or hyper)
5. ◘   Thromboembolic disease
6. ◘   Asthma

Hospital Admissions: when, where and why.
Surgical procedures

1. ◘   when, where, why and details concerning procedure
2. ◘   abdominal or gynaecological procedures
3. ◘   problems with anaesthesia
4. ◘   problems with bleeding (requiring transfusion) or clotting

Vaccinations/immunisations up to date?

Current Medications & Allergies
Medications can be divided into prescribed medications and non-prescribed medications/herbal remedies. The latter should not be missed, and approached in non-judgemental way.
Allergic to any medications?

Family History

1. ◘   Medical conditions
2. ◘   Obstetric complications
3. ◘   Genetic conditions

Social History

1. ◘   Occupation
2. ◘   Relationship Status
3. ◘   Diet/physical activity
4. ◘   Smoking
5. ◘   Alcohol
6. ◘   Drug use
7. ◘   Living Situation
8. ◘   Travel History

References

1. ◘   ABC of labour care - Obstetric emergencies http://www.bmj.com.ezproxy.library.uq.edu.au/content/318/7194/1342
2. ◘   Borton, Chloe (November 12, 2009). "Gravidity and Parity Definitions (and their Implications in Risk Assessment)".
3. ◘   The Medical Significance of the Obstetric H... [Am Fam Physician. 1983] - PubMed - NCBI.

A small collection of Obstetric summaries that I made whilst studying for my exams, that I thought would share with the greater world. They cover aspects like clinical features, investigations, risk factors and basic management.

If something is wrong with any of them let me know and I'll make a note of it here. They're all solo takes, so it may seem a little all over the place with plenty of 'ums' and 'ahhs'.

Preterm Labour

Just a note, though I didn't state it preterm labour is obviously labour before term.

Link

Gestational Diabetes

Link

Pre-eclampsia

Link

Obesity in Pregnancy

Link

Ectopic Pregnancy

Link

VTE Prophylaxis in Pregnancy

Link

 

JAM aka Just A Minute Medicine is a concept of quickly presenting the most pertinent facts in a video format. They are designed to act as quick refreshers of the most important information, that will guide clinical practice.

This video by Dr Tim Leeuwenburg from KIDoc.org explains the concept.

JAM series from Tim Leeuwenburg on Vimeo.

 There a quite few videos available online now following the JAM format; with topics like
Rapid Sequence Intubation through to a simple guide on how to use a turbuhaler device.

Obstetrics and Gynaecology Collection
The focus on this post however, will be to highlight some of the useful Obstetric and Gynaecology tutorials.

Why you ask? Because I just so happen to be on my Obstetrics and Gynaecology term.

And that's all the JAM folks.

Checkout Short Podcasts on Obstetrics for some more material.

It's been over 3 and half years seen I wrote my original Top Online Resources for Medical Students, and we have come a long way. While there are still some of the old-favourites hanging around, there are also a whole bunch of newcomers to the online sphere. 

So after initially writing a list at the start of medical school, I'm now writing one at the end. This is by no means a comprehensive list, rather a list of resources that I found particularly useful throughout my medical school life. Feel free to add you own top resources in the comments section below.

Please note the majority of resources included in this list are all freely available, however some more comprehensive options do exist that require payment/subscription. I also recommending checking what online resources are provided by your Medical School/Hospital.

General
LifeintheFastLane

www.lifeinthefastlane.com

Lifeinthefastlane (LITFL) is one of my all time favourite resources, and probably the one I've used most on a regular basis. LITFL is a blog targeted at sharing emergency medicine and critical care knowledge, yet it's whole library of posts offers up much more to the reader.

Due to it's awesomeness, I'm not going waste any more time apart from saying, Go Check It Out!

Global Medical Education Project

www.gmep.org

The Global Medical Education Project (covered in a previous post) is a repository of medical information, images, videos and questions. It is an interactive network allowing people to tag media, vote questions up and down and comment on work.

The NNT

www.thennt.com

An Evidence Based Medicine (EBM) website evaluating therapies and diagnostics. It is a useful resource to use to see an overview of the evidence behind different therapies and diagnostics. Cover a range of specialities from Cardiology through to Urology.

GuidelinesForMe
www.guidelinesforme.com

A database of guidelines collated from around the globe.

MDCalc

www.mdcalc.com

A medical calculator and equations website for clinical calculations, scores, equations, outcomes, mortality and risk stratifications.

SketchyMedicine
www.sketchymedicine.com
I'm a very visual learner and SketchyMedicine is one of the blogs I frequently stop by to have a look.
There are some great doodles that cover a number of aspects of medicine; everything from internal medicine through to basic anatomy.

Khan Academy
www.khanacademy.org
Khan Academy is a huge educational initiative comprising of 100s of videos. Best used for learning your basic sciences, or maybe just learning something new entirely.

You can also access their library on your mobile or tablet through the KhanApp.

Handwritten Tutorials 
www.handwrittentutorials.com
Simple. Handwritten video tutorials on basic physiology and anatomy. If you're a visual learner like me than these are high yield.

Lab Tests Online
http://www.labtestsonline.org.au/
Labs tests online helps the clinician understand clinical laboratory tests. It provides information on individual tests (e.g. eLFTs), on tests for diagnosing or asessing (e.g. Anaemia) and tests for certain population groups (e.g. neonates). It contains information that has been localised to more than 15 different countries (from Australia through to the United States of America).

Android and iPhone apps are also available.

Anatomy

BioDigital Human
https://www.biodigitalhuman.com/home/
The BioDigital Human is a virtual 3D body that brings to life thousands of medically accurate anatomy objects and health conditions in an interactive Web-based platform.

Zygote Body
http://www.zygotebody.com/
An offshoot of the original GoogleBody, Zygote body provides another 3D view of the human body.

AnatomyZone
http://www.anatomyzone.com/
AnatomyZone harnesses some of the above resources to create Anatomy tutorials useful to a wide range of different users, from nurses, to physiotherapists, to osteopaths, to medical students.

Clinical Examination
The Stanford Medicine 25
http://stanfordmedicine25.stanford.edu/the25
This website produced by Stanford covers 25 common clinical examinations. It includes the usual collection of text, images and videos.

GeekyMedics
http://geekymedics.com
A popular site amongst many medical students, GeekyMedics covers the basics of history taking and clinical examination in an easy and friendly way. Aside from their clinical examination posts, they also have a collection of posts relevant to OSCEs, Medicine, Surgery and Emergency.

There is also a clinical skills section on IVLine, which has a number of useful videos from the University of London.

Cardiology
ECGPedia
http://en.ecgpedia.org/
A free electrocardiography (ECG) tutorial and textbook to which anyone can contribute ,
pitched at medical professionals and keen medical students. Also includes a number of case studies.
If you're looking for a place to start in understanding ECG this is one I would recommend.

Profmontage
http://www.profmontage.com.au
ProfMontage provides a video tutorial series on clinical cardiology, cardiac physiology and clinical epidemiology. The videos are short and snappy (being all less than 3 minutes) and features a cast of characters from Xtranormal.

You may recognise the use of XtraNormal from this classic Orthopaedic vs Anaesthesia Battle.

LearntheHeart
http://www.learntheheart.com/
Learn the heart is a website highlighting some of the big ticket items in cardiology.

Blaufuss Multimedia
http://www.blaufuss.org/
Want to hear a heart murmur? Blaufuss Multimedia has a number of tutorials on hearts sounds, as well as ECG and arrhythmias.

CV Physiology
http://www.cvphysiology.com/Tutorials/tutorials.htm
Tutorials and quizzes on cardiovascular physiology; from arrhythmias through to peripheral artery disease.

Quick Guide to ECG
http://www.ivline.org/2010/05/quick-guide-to-ecg.html
The most popular post on IVLine, this post gets people coming back time and time again. It runs through the basics of ECG and provides a quick guide on how to report an ECG back to a colleague.

Emergency Medicine
Note emergency medicine is renowned for a having very active group of clinicians and students worldwide publishing content. While I would love to include everyone on this list, I resorted to selecting just a few of my regulars. If you wish to find more it's worth checking out #FOAMed on twitter which is where all the emergency physicians spend their days.

AcademicLifeinEM
http://academiclifeinem.com/
Academic Life in EM started by Michelle Lin (@M_Lin), provides a wealth of resources on Emergency Medicine topics. With consistently good content, this is not one to miss. My two personal picks from this site are; Tricks of Trade and her Paucis Verbis (PV) cards. The PV cards are available on iOS, Android, Evernote or Dropbox.

Patwari Academy
http://www.youtube.com/user/oldblueday
If you haven't realised by now, I'm a bit of a visual learner. Patwari Academy is a series of video tutorials on emergency medicine and evidence based practice by Rahul Patwari. The videos are broken down into digestible bits, with often a topic like Advance Life Support running over a number of videos.

EMCrit
http://emcrit.org/
Scott Weingart (@EMCrit) the author of EMCrit, too many feels like the god of Critical Care. Not surprisingly his blog is a gold mine. While I wouldn't recommend this blog to kids just kicking off their medical training, this is one for anyone passionate about critical care.

Anatomy for Emergency Medicine
http://emergencymedicineireland.com/anatomy-and-em/
Anatomy for Emergency Medicine is a podcast series which delivers doses of anatomical knowledge linked in with clinical scenarios. Often we learn anatomy simple as remember this goes here and does this. These podcasts series, ties our anatomical knowledge (or lack thereof) into the clinical scenarios some may face on a day to day basis.

Ultimate Guide to Trauma
http://www.ivline.org/2012/04/ultimate-guide-to-trauma.html
The Ultimate Guide to Trauma is a collection of posts from blogs like Lifeinthefastlane, Academic Life in EM, EMCrit and so on, which offers a starting point for those interested in understanding the approach to trauma in general and specific scenarios.

Histology/Pathology 

Blue Histology
http://www.lab.anhb.uwa.edu.au/mb140/
A collection of images, notes and quizzes from the University of Western Australia.

Shotgun Histology
http://www.youtube.com/user/WashingtonDeceit
Another long-standing favourite of medical students. Shotgun histology features selection of videos investigating the histology of different tissues. A highly valuable resource for those who have had no experience in histology. To watch in a series, view this playlist.

 

PathologyStudent
http://www.pathologystudent.com/
Pathology Student's motto is 'making pathology easy and fun. While I can't comment on the fun part (being not a huge fan of pathology) it certainly makes it a bit easier and in my opinion bearable. Pathology student is regularly updated and has some useful study guides.

Internal Medicine
Internal Medicine Introductory Lecture Series
http://www.uth.tmc.edu/schools/video/streamvideo/ms/im/imedls.html
A series of video lectures from the University of Texas on internal medicine topics.

Clinical Cases
http://clinicalcases.org/
Clinical Cases and Images is a useful resource that brings together various pearls of medical wisdom and aims to bridge the gap between clinical theory and practice. It is a well supported and recommended blog, having been featured in 14 peer-reviewed medical journals and other scientific publications.

General Practice
GPnotebook
http://www.gpnotebook.co.uk/
GPnotebook is an online encyclopaedia of medicine pitched at general practitioners.

FamilyPractice Notebook
http://www.fpnotebook.com
Almost like the younger cousin of GPnotebook. Between the two you should be able to find what you are looking for.

Nephrology

Nephrology On-Demand

www.nephrologyondemand.org

Nephrology on Demand from the University of Eastern Carolina is a regularly updated website, with pearls, histopathology, videos and general renal goodness.

Precious Bodily Fluids
http://www.pbfluids.com/
Handouts, powerpoints and a handful of blog posts since 2007, Precious Bodily Fluids is another a would recommend to get started with nephrology.

Neurology

Rather than do too much leg work, when I see a good resource I share it. Eve Purdy from Manu et Corde has put together a list of useful neurology resources.

Draw it to know it
http://www.drawittoknowit.com
Not exactly free (except for a free trial) and not strictly neurology, Draw it to know it is a site that gets you to draw neuroanatomy to remember it. I include it here, as I've found it useful at times; for both myself and students I've taught neuroanatomy too.

Ophthalmology
OphthoBook
http://www.ophthobook.com/
OphthoBook is what I would call the simple guide to Ophthalmology. In fact, for medical students I would probably just call it the complete guide. Written by Dr Tim Root, it contains some funky cartoon images, videos galore and all the basics you need to know about Ophthalmology.

The Eyes Have It
http://www.kellogg.umich.edu/theeyeshaveit/
An tutorial and quiz website provided by the University of Michigan. Though I like to think of it as an atlas with some questions. Best of all if you're looking to share all their content is licensed under creative commons.

IVLine: Clinical Examination of the Eye

Orthopaedics
AO Surgery
https://www.aofoundation.org/wps/portal/surgery
The AO Surgery Reference is a huge online repository of surgical knowledge, consisting of more than 7000 pages. It overviews surgical procedures, surgical decision making, and has an abundance of images and videos Simply select an area of anatomy then work through Diagnosis, Indication, Preparation, Approach, Reduction & Fixation and Aftercare.

Plus it can be accessed on you smartphone or tablet.

WorldOrtho
http://www.worldortho.com/
WorldOrtho is a site dedicated to Orthopaedic resources and learning. The Simple Guide to Orthopaedics and the Simple Guide to Trauma are two useful ebooks.

Videos by Dr Nabil Ebraheim
http://www.youtube.com/user/nabilebraheim/videos
Videos on anatomy, signs and symptoms. Plus a few of the common rheumatological and orthopaedic conditions.

Wheeless' Textbook of Orthopaedics
http://www.wheelessonline.com
To be honest I'm really not a fan of this site, but it gets recommended to me so often I've included it here. I'm sure the information is actually pretty good, but the layout and design, just make we want to stay well clear of this site.

Paediatrics
Royal Childrens Hospital (Melbourne)
http://www.rch.org.au/clinicalguide/
A complete suite of clinical practice guidelines and tips developed by a team of paediatricians. Updated frequently and available on your mobile devices.

Pediatric Surgery Handbook
http://med.brown.edu/pedisurg/Handbook.html
A quick and easy guide on the basics of Paediatric Surgery provided by Brown University.

There are a collection of paediatric resources available at www.generalpediatrics.com

Radiology
Radiopaedia
http://radiopaedia.org/
A huge encyclopaedia of radiology knowledge. It has over 13000 cases, nearly 6000 articles which continues to all the time. Nearly anyone can be part of it, and it can accessed through their dedicated mobile apps.

Radiology Masterclass

http://www.radiologymasterclass.co.uk/
Whereas Radiopaedia feels like a reference site or wiki to all radiological knowledge, Radiology Masterclass has a structured tutorial breakdown. This allows you to work step-by-step through areas of firstly interest (e.g. by anatomy) followed by skill level.

Rural Practice
Rural Doctors
http://ruraldoctors.net/
This site is for clinicians who want to keep in touch with the latest in medical education concepts applicable to rural practice, listen to relevant podcasts and share thoughts on typical cases, using info from the wider medical education community.

Surgery
SurgWiki.com
http://surgwiki.com/
Surgwiki is brought to you by the ANZ Journal of Surgery and has a number of contributors and editors from across the globe. It is broken down into four main components; General concepts, Surgical technique, Peri-operative care and Specialty interests.

Subscription Services

Here are some paid services I particularly like.

• BMJ Best Practice
• MDConsult
• AccessMedicine

I used to be a fan of Uptodate however it's not as useful to an Australian practitioner. In addition, BMJ Best Practice provides a great iPad App.

Summary
So that's a wrap-up of some of the resources I found most useful during my medical degree. I have obviously not had the chance to do every speciality throughout my years of training. And a few of the resources have obviously been due to their relevance to the Australian practitioner.

So I encourage everyone to share of their favourite below in the comments section or on twitter under #FOAMed.

Photo Atrribution

• Studying by Saad Faruque